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Question 1Question →

A nurse is analyzing the physiological data of a client who is 3636 hours post-operative following an exploratory laparotomy for an ischemic bowel. The client is intubated, mechanically ventilated, and has an arterial line and a central venous catheter in place. The latest assessment data reveals the following:

ParameterCurrent Value
Heart Rate138 bpm138\text{ bpm}
Blood Pressure78/42 mm Hg (MAP 54 mm Hg)78/42\text{ mm Hg (MAP } 54\text{ mm Hg)}
Central Venous Pressure (CVP)2 mm Hg2\text{ mm Hg}
Systemic Vascular Resistance (SVR)550 dynes/sec/cm−5550\text{ dynes/sec/cm}^{-5}
Serum Lactate6.8 mmol/L6.8\text{ mmol/L}
pH7.187.18
PaCO2\text{PaCO}_258 mm Hg58\text{ mm Hg}
PaO2\text{PaO}_254 mm Hg54\text{ mm Hg}
HCO3−\text{HCO}_3^-14 mEq/L14\text{ mEq/L}

Based on these findings, which of the following conclusions and corresponding nursing actions are correct? (Select all that apply)

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Answer: The arterial blood gas values reveal a mixed respiratory and metabolic acidosis; anticipate adjusting the mechanical ventilator settings to increase minute ventilation.; The systemic vascular resistance and mean arterial pressure indicate profound vasodilation; prepare to administer a prescribed continuous vasopressor infusion once intravascular volume is restored.; The elevated serum lactate in conjunction with the hemodynamic profile reflects severe tissue hypoperfusion; anticipate the rapid administration of intravenous isotonic crystalloids.

Answer

The correct conclusions are that the client is experiencing a mixed respiratory and metabolic acidosis requiring increased minute ventilation, profound vasodilation requiring vasopressors after volume restoration, and severe tissue hypoperfusion requiring rapid isotonic crystalloids.
The physiological data provided describes a client in severe distributive (septic) shock complicated by a mixed acid-base disorder. The low systemic vascular resistance and low central venous pressure confirm massive vasodilation and relative hypovolemia, necessitating aggressive isotonic fluid resuscitation followed by vasopressors to maintain a mean arterial pressure above 65 mm Hg65\text{ mm Hg}. The elevated lactate level directly reflects anaerobic metabolism due to this severe tissue hypoperfusion. Furthermore, the arterial blood gases reveal a pH of 7.187.18 with both an elevated PaCO2\text{PaCO}_2 (respiratory acidosis) and a decreased HCO3−\text{HCO}_3^- (metabolic acidosis). Because both systems are deranged in the acidic direction, this is a mixed acidosis, and adjusting the ventilator to increase minute ventilation is the appropriate intervention to address the respiratory component.

Step-by-Step Solution

1
Analyze the hemodynamic parameters to determine the type of shock.
The low CVP (2 mm Hg2\text{ mm Hg}) indicates relative or absolute hypovolemia, while the low SVR (550 dynes/sec/cm−5550\text{ dynes/sec/cm}^{-5}) indicates massive vasodilation. Combined with a low MAP (54 mm Hg54\text{ mm Hg}), this profile definitively points to distributive (septic) shock.
Identifying the specific shock state is crucial for determining the correct physiological interventions (fluids and vasopressors rather than inotropes or diuretics).
2
Interpret the arterial blood gas (ABG) values.
The pH is 7.187.18 (severe acidemia). The PaCO2\text{PaCO}_2 is 58 mm Hg58\text{ mm Hg} (respiratory acidosis) and the HCO3−\text{HCO}_3^- is 14 mEq/L14\text{ mEq/L} (metabolic acidosis). This represents a mixed respiratory and metabolic acidosis.
Because both the respiratory and metabolic parameters are abnormal in the acidic direction, neither is compensating; both are actively contributing to the life-threatening acidemia.
3
Evaluate tissue oxygenation and cellular metabolism.
The serum lactate is markedly elevated at 6.8 mmol/L6.8\text{ mmol/L} (normal is typically <2.0 mmol/L< 2.0\text{ mmol/L}).
High lactate confirms that inadequate oxygen delivery to the tissues has forced cells into anaerobic metabolism, confirming severe hypoperfusion.
4
Select the appropriate corresponding nursing actions based on the physiological data.
The client urgently needs intravenous isotonic crystalloids to correct the hypoperfusion, vasopressors to reverse the profound vasodilation if fluids are insufficient, and adjustments to the mechanical ventilator to resolve the respiratory acidosis component.
These interventions directly target the underlying pathophysiological derangements identified in the assessment.

Key Concept

Interpretation of complex hemodynamic parameters and mixed acid-base disorders in distributive (septic) shock.
Question 2Question →

A nurse is assessing a client who is 4 hours post-operative following a total thyroidectomy. Which assessment findings should indicate to the nurse that the client is developing a severe physiological complication requiring immediate intervention? Select all that apply.

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Answer: Tingling and numbness around the mouth and distal extremities; A harsh, high-pitched sound auscultated over the trachea during inspiration; The client reports a progressive sensation of pressure and fullness in the neck

Answer

The assessment findings that indicate a severe complication requiring immediate intervention are tingling and numbness around the mouth and distal extremities, a harsh, high-pitched sound auscultated over the trachea during inspiration, and a progressive sensation of pressure and fullness in the neck.
The correct findings directly correspond to the three major, life-threatening complications of a thyroidectomy. Tingling and numbness around the mouth (circumoral paresthesia) and distal extremities are early indicators of hypocalcemia due to inadvertent damage to or removal of the parathyroid glands. A harsh, high-pitched sound on inspiration (stridor) is a sign of acute airway obstruction caused by laryngeal edema or recurrent laryngeal nerve damage. A progressive sensation of pressure and fullness in the neck is a hallmark sign of hemorrhage and an expanding hematoma, which can rapidly compress the trachea.

Step-by-Step Solution

1
Analyze the clinical scenario
The client is 4 hours post-operative following a total thyroidectomy.
Identifying the specific surgical procedure and timeframe helps anticipate the early post-operative complications that are most critical to monitor for.
2
Identify potential life-threatening complications of a total thyroidectomy
The major physiological complications include airway obstruction (due to laryngeal edema or recurrent laryngeal nerve damage), hemorrhage or expanding hematoma, and hypocalcemia (due to parathyroid gland damage).
Recognizing these specific risks allows the nurse to prioritize assessment findings that require immediate emergency intervention.
3
Evaluate each assessment finding against known complications and expected post-operative data
Tingling indicates hypocalcemia. Stridor indicates airway obstruction. Neck pressure indicates an expanding hematoma. Conversely, scant drainage, normal arterial blood gases, and a semi-Fowler's position are expected and safe findings.
Differentiating between expected post-operative findings and signs of severe physiological compromise is essential for accurate clinical judgment and risk reduction.

Key Concept

Early recognition of life-threatening complications following a total thyroidectomy, specifically airway compromise, hemorrhage, and hypocalcemia.
Question 3Question →

A nurse is developing a discharge plan for a client with advanced heart failure. The client requires home oxygen therapy equipment, needs to learn energy conservation techniques for bathing, and requires initial education on a strict low-sodium diet. The client expresses anxiety about managing these changes at home. Which collaborative actions should the nurse include in the plan of care? (Select all that apply.)

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Answer: Consult the facility case manager to coordinate the delivery of home oxygen equipment.; Request a referral to occupational therapy to teach the client energy conservation strategies during bathing.; Collaborate with a registered dietitian to provide comprehensive education regarding the low-sodium diet.

Answer

The correct actions are consulting the case manager for oxygen equipment, requesting occupational therapy for bathing strategies, and collaborating with a registered dietitian for dietary education.
The correct collaborative actions appropriately utilize the interdisciplinary team based on their distinct scopes of practice. Case managers handle resource coordination (oxygen), occupational therapists address activities of daily living (bathing), and dietitians manage complex nutritional education (low-sodium diet).

Step-by-Step Solution

1
Analyze the client's specific discharge needs.
The client requires home oxygen, bathing modifications, and specialized dietary teaching.
Identifying specific deficits and needs is the first step in determining which interdisciplinary team members are required.
2
Match the identified needs to the appropriate allied health scopes of practice.
Oxygen coordination matches the case manager, ADL modifications match the occupational therapist, and nutritional teaching matches the dietitian.
Effective collaboration requires an accurate understanding of each team member's role and expertise.
3
Evaluate the remaining options for safety and therapeutic communication.
Delegating initial teaching to UAP, delaying discharge planning, and providing false reassurance are identified as incorrect actions.
These actions violate principles of safe delegation, care prioritization, and therapeutic communication.

Key Concept

Interdisciplinary Team Roles and Scope of Practice
Estimated Time:1m 0s
Question 4Question →

While completing morning rounds, a nurse assesses a client who underwent a partial colectomy the previous day. The client is receiving continuous intravenous fluids and utilizing a morphine patient-controlled analgesia (PCA) device. The nurse observes that the client is profoundly somnolent, minimally responsive to tactile stimuli, and exhibits shallow respirations at a rate of 7 breaths per minute with an oxygen saturation of 85% on room air. Which immediate interventions are appropriate to mitigate further physiological risk? Select all that apply.

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Answer: Pause the continuous infusion and patient-initiated doses of the morphine PCA.; Prepare to administer intravenous naloxone as prescribed by the healthcare provider.; Apply supplemental oxygen and stimulate the client to take deep breaths.

Answer

The correct interventions for suspected opioid-induced respiratory depression include pausing the PCA pump, preparing and administering naloxone, and applying supplemental oxygen while stimulating the client.
The client is exhibiting classic signs of acute opioid toxicity: profound sedation, significant bradypnea (7 breaths per minute), and hypoxia. The immediate priority is to stop the administration of the offending medication by pausing the PCA pump. Naloxone is an opioid antagonist that rapidly reverses respiratory depression and must be administered promptly. Concurrently, applying supplemental oxygen and physically stimulating the client helps manage the severe hypoxia and encourages spontaneous ventilation.

Step-by-Step Solution

1
Identify the clinical emergency based on the assessment data.
The client has a respiratory rate of 7 breaths per minute, an oxygen saturation of 85%, and profound somnolence.
These are classic signs of opioid toxicity and impending respiratory failure, requiring immediate intervention.
2
Prioritize immediate life-saving interventions utilizing the ABCs (Airway, Breathing, Circulation).
Interventions that protect the airway, restore breathing, and reverse the medication's effects are selected first.
Without adequate oxygenation and ventilation, irreversible neurological damage or cardiac arrest can occur.
3
Eliminate the source of the toxicity and administer the specific antidote.
The morphine PCA is stopped immediately, supplemental oxygen is applied, and intravenous naloxone is prepared.
Naloxone competitively binds to opioid receptors, rapidly reversing the central nervous system and respiratory depression caused by the morphine.

Key Concept

Management of Opioid-Induced Respiratory Depression
Question 5Question →

A registered nurse coordinating an occupational health and wellness program at a corporate facility is planning activities for the upcoming fiscal year. Which of the proposed activities should the nurse classify as primary prevention strategies? Select all that apply.

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Answer: Providing prophylactic tetanus-diphtheria-pertussis (Tdap) vaccinations to warehouse personnel.; Teaching proper biomechanics and safe lifting techniques to newly hired manufacturing staff.; Implementing a facility-wide healthy nutrition and smoking cessation education campaign.

Answer

The primary prevention strategies are providing prophylactic Tdap vaccinations, teaching proper biomechanics, and implementing a healthy nutrition and smoking cessation campaign.
Primary prevention strategies are designed to prevent disease, illness, or injury before they occur. These interventions involve health promotion, education, and specific protection measures. Providing immunizations, teaching proper body mechanics to prevent workplace injuries, and educating staff on healthy lifestyle choices (like nutrition and smoking cessation) all actively work to stop health issues from developing in a healthy population. Therefore, they are all correctly classified as primary prevention.

Step-by-Step Solution

1
Recall the definition of primary prevention.
Primary prevention focuses on health promotion and protection against specific health problems before they ever occur.
Establishing the correct definition is necessary to differentiate primary interventions from secondary (screening) and tertiary (rehabilitation) interventions.
2
Evaluate each proposed activity against the definitions of the prevention levels.
Vaccinations, safety training, and health education campaigns prevent disease or injury before occurrence (primary). Spirometry testing aims for early detection (secondary). Exercise therapy for coronary artery disease and support groups for recovery focus on managing existing conditions (tertiary).
Systematically categorizing each option ensures accurate selection based on the clinical intent of the intervention.
3
Select all options that represent primary prevention.
The correct choices are the Tdap vaccinations, biomechanics teaching, and the education campaign.
These three actions meet the criteria for preventing pathology before it begins.

Key Concept

Levels of Disease Prevention
Question 6Question →

A 65-year-old client is admitted to the progressive care unit 2 hours after a cardiac catheterization utilizing the right femoral artery approach. The provider prescribes strict supine bed rest with the affected extremity kept straight for 6 hours. The client reports a severe backache, feels hungry, and states an urgent need to void. Which nursing actions are appropriate to address the client's basic care and comfort needs? Select all that apply.

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Answer: Slide a thin, rolled blanket under the lumbar region of the spine; Utilize a fracture bedpan for urinary elimination while ensuring the right leg remains fully extended; Apply a heel-suspension boot to the right lower extremity while keeping the leg in neutral alignment

Answer

The correct interventions are providing a lumbar roll for comfort, using a fracture bedpan for elimination, and applying a heel-suspension boot to protect skin integrity.
The correct interventions successfully balance the client's fundamental needs for comfort, elimination, and skin protection with the strict physiological requirement to keep the right hip straight. Using a lumbar roll, a fracture bedpan, and a heel protector achieve these basic care goals without compromising the vascular puncture site.

Step-by-Step Solution

1
Analyze the client's clinical constraints
The client has a right femoral arterial puncture requiring strict flat bed rest and right leg immobilization.
Establishing physical limitations is necessary before implementing basic care interventions.
2
Evaluate comfort interventions for the reported backache
A lumbar roll is safe and effective; instructing the client to bend their knees is contraindicated due to required hip flexion.
Back pain is common during flat bed rest, but interventions must not alter the required straight alignment of the affected leg.
3
Evaluate elimination interventions
Using a fracture bedpan is appropriate because it requires minimal lifting and prevents hip flexion.
The client needs to void, but mobilizing to a commode or using a standard bedpan threatens the puncture site.
4
Evaluate positioning for nutrition
Sitting the client upright (high Fowler's) is strictly contraindicated.
Hip flexion above 15-30 degrees (depending on specific protocol) risks dislodging the arterial clot and causing hemorrhage.
5
Evaluate delegation and hygiene tasks
Delegating the assessment of pedal pulses is inappropriate.
Unlicensed personnel can perform the hygiene, but the RN must conduct all vascular assessments.
6
Evaluate skin integrity interventions
Applying a heel-suspension boot is a correct proactive measure.
Strict immobility rapidly increases the risk of heel breakdown; the boot provides protection while keeping the leg straight.

Key Concept

Providing fundamental care (elimination, comfort, skin integrity) while adhering to strict procedural immobility constraints.
Question 7Question →

A client is admitted to the inpatient medical unit with severe abdominal cramping and frequent watery stools. Laboratory results confirm an active Clostridioides difficile (C. diff) infection. Which of the following infection control measures should the nurse implement? Select all that apply.

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Answer: Perform hand hygiene using soap and water after providing client care.; Don a protective gown and clean gloves prior to entering the client's room.; Ensure dedicated medical equipment, such as a stethoscope and blood pressure cuff, remains in the client's room.

Answer

The correct measures include performing hand hygiene with soap and water, donning a gown and gloves before entering the room, and using dedicated medical equipment.
Clostridioides difficile (C. diff) requires strict contact precautions because it is easily spread through direct contact with the client or contaminated surfaces. These precautions mandate wearing a gown and gloves upon entering the room and dedicating medical equipment to the client to prevent cross-contamination. Uniquely, because C. diff forms highly resilient spores that are unaffected by alcohol-based hand rubs, healthcare personnel must rigorously perform hand hygiene using soap and water to mechanically wash the spores away.

Step-by-Step Solution

1
Identify the pathogen and its mode of transmission.
The pathogen is Clostridioides difficile, which is transmitted via the fecal-oral route and forms highly resilient spores.
Understanding the pathogen dictates the specific tier of isolation precautions required.
2
Determine the appropriate transmission-based precautions.
Contact precautions must be initiated.
Contact precautions protect healthcare workers and other clients from pathogens spread by direct or indirect contact with the client or their environment.
3
Identify specific environmental and hygiene interventions unique to this pathogen.
Soap and water must be used instead of alcohol rub, and dedicated equipment should remain in the room.
Alcohol-based sanitizers do not kill C. diff spores, so mechanical friction with soap and water is necessary.

Key Concept

Contact Precautions for Clostridioides difficile
Question 8Question →

A critically ill client admitted with diabetic ketoacidosis (DKA) has a serum potassium level of 2.82.8 mEq/L. The healthcare provider prescribes an intravenous infusion of 2020 mEq potassium chloride (KCl) in 100100 mL of 0.9%0.9\% sodium chloride to be administered over 11 hour. The client has a double-lumen central venous catheter (CVC) in the right internal jugular vein. A continuous regular insulin infusion is actively running through the distal lumen. Which of the following actions should the nurse take regarding the potassium chloride administration? (Select all that apply.)

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Answer: Administer the solution through the proximal CVC lumen using an electronic infusion pump.; Verify that the client has produced at least 3030 mL/hr of urine before initiating the infusion.; Ensure the client is connected to a continuous electrocardiogram (ECG) monitor during the infusion.; Aspirate the proximal CVC lumen for a brisk blood return prior to starting the infusion.

Answer

The correct actions include administering the solution through the available proximal lumen using an electronic pump, verifying adequate urine output, ensuring continuous ECG monitoring, and aspirating for a blood return.
Intravenous potassium chloride is a high-alert medication that requires strict adherence to safety protocols. Because the prescribed rate (2020 mEq/hr) exceeds the standard peripheral limit (1010 mEq/hr), continuous ECG monitoring is mandatory to detect potential cardiac arrhythmias. The nurse must also verify renal function (urine output of at least 3030 mL/hr) to ensure the client can excrete the potassium and avoid hyperkalemia. Furthermore, since potassium is a severe tissue irritant and vesicant, central line patency must be confirmed by aspirating for a brisk blood return before infusion. Finally, an electronic infusion pump is always required to guarantee precise delivery and prevent an accidental rapid bolus.

Step-by-Step Solution

1
Analyze the prescription and the client's current intravenous access.
The client requires a high-concentration potassium infusion (2020 mEq/hr) and has an available dedicated lumen on a central venous catheter.
Determining the rate and route is essential for identifying the required safety protocols for high-alert medications.
2
Identify the mandatory safety parameters for high-dose intravenous potassium.
Administration requires an electronic volumetric pump, continuous ECG monitoring (due to the rate >10> 10 mEq/hr), and verification of renal function (urine output ≥30\geq 30 mL/hr).
Potassium is primarily excreted by the kidneys and rapid administration can cause fatal cardiac arrhythmias.
3
Evaluate central line administration and medication compatibility principles.
The available proximal lumen should be used after confirming patency via blood aspiration. Connecting to the insulin line without checking compatibility is unsafe.
Potassium is a vesicant that can cause tissue necrosis if extravasated, and manipulating continuous high-alert infusions (like insulin) should be avoided.

Key Concept

Safe Administration of Parenteral Potassium Chloride and Central Line Management
Question 9Question →

An interdisciplinary team is conducting rounds on a medical-surgical unit housing clients with various infectious diseases. Which of the following observed practices indicate correct adherence to transmission-based precautions? Select all that apply.

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Answer: Wearing a standard surgical mask when measuring the blood pressure of a client diagnosed with pertussis.; Placing a standard surgical mask on a client with active pulmonary tuberculosis during transport to the radiology department.; Donning a gown and clean gloves prior to entering the room of a client with a methicillin-resistant Staphylococcus aureus (MRSA) wound infection.

Answer

The correct practices are wearing a surgical mask for pertussis, placing a standard mask on a client with tuberculosis during transport, and donning a gown and gloves before entering an MRSA room.
Appropriate transmission-based precautions are essential to prevent the spread of infectious agents. Pertussis requires droplet precautions, meaning healthcare workers must wear a standard surgical mask when in close contact. For clients with airborne infections like pulmonary tuberculosis, a standard surgical mask must be placed on the client during transport to trap their respiratory secretions. Methicillin-resistant Staphylococcus aureus (MRSA) requires contact precautions; thus, entering the client's room requires donning a gown and gloves to prevent cross-contamination.

Step-by-Step Solution

1
Identify the mode of transmission and required isolation tier for each pathogen mentioned.
Pertussis (Droplet), Norovirus (Enteric Contact), Tuberculosis (Airborne), Varicella (Airborne/Contact), MRSA (Contact), and Neisseria meningitidis (Droplet).
Correct PPE and environmental controls are dictated by the specific transmission route of the organism.
2
Evaluate the personal protective equipment (PPE) utilized by the staff for the specific pathogens.
Using a surgical mask for pertussis and gown/gloves for MRSA align with CDC guidelines. However, removing an N95 inside an airborne room violates protocols.
Staff PPE must intercept the pathogen correctly; airborne pathogens require respirators to be worn until fully outside the room.
3
Assess the interventions related to client management and environmental control.
Masking a client with tuberculosis during transport is correct. Using alcohol rub for norovirus and cohorting different types of meningitis are unsafe practices.
Alcohol does not efficiently kill enteric viruses like norovirus, and mixing different pathogens risks nosocomial cross-infection.

Key Concept

Standard and Transmission-Based Precautions
Question 10Question →

A nurse is evaluating a client who was intubated and placed on mechanical ventilation 22 hours ago for acute respiratory failure. Current assessment findings include a heart rate of 132132 bpm, blood pressure of 86/5286/52 mm Hg, and cool, pale extremities. The latest arterial blood gas (ABG) results are pH 7.267.26, PaCO2PaCO_2 6262 mm Hg, HCO3−HCO_3^- 2525 mEq/L, and PaO2PaO_2 5858 mm Hg. Based on these assessment findings, which of the following clinical judgments and nursing actions are appropriate? Select all that apply.

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Answer: Analyze the arterial blood gas values as indicative of an uncompensated acid-base imbalance of respiratory origin.; Recognize the vital signs and peripheral assessment findings as clinical indicators of a shock state.

Answer

The correct clinical judgments are concluding that the ABG demonstrates an uncompensated acidotic state of respiratory origin and recognizing the vital signs as indicators of a shock state.
The arterial blood gas results show a pH less than 7.357.35 and a PaCO2PaCO_2 greater than 4545 mm Hg, which indicates an acidotic state of respiratory origin. Because the bicarbonate (HCO3−HCO_3^-) level is within the normal range of 22−2622-26 mEq/L, there is no metabolic compensation. Furthermore, the combination of tachycardia, hypotension, and cool, pale extremities strongly indicates inadequate tissue perfusion and compensatory vasoconstriction, which are classic early signs of a shock state.

Step-by-Step Solution

1
Analyze the arterial blood gas (ABG) values.
pH is 7.267.26 (acidosis), PaCO2PaCO_2 is 6262 mm Hg (respiratory origin), and HCO3−HCO_3^- is 2525 mEq/L (normal, indicating it is uncompensated).
To determine the client's acid-base status and evaluate the effectiveness of the mechanical ventilation.
2
Evaluate the hemodynamic parameters and physical assessment findings.
Heart rate is 132132 bpm, blood pressure is 86/5286/52 mm Hg, and extremities are cool and pale.
To identify signs of inadequate tissue perfusion or impending cardiovascular collapse.
3
Synthesize the findings to determine appropriate clinical conclusions and interventions.
The client has an uncompensated respiratory acid-base imbalance and is exhibiting signs of a shock state.
To prioritize care and avoid harmful interventions, such as elevating the head of the bed during severe hypotension.

Key Concept

Early recognition of shock and accurate interpretation of uncompensated acid-base imbalances are critical for prioritizing interventions and preventing hemodynamic collapse in mechanically ventilated clients.
Question 11Question →

A nurse assumes care for a client with severe Crohn's disease who is malnourished and receiving Total Parenteral Nutrition (TPN) via a peripherally inserted central catheter (PICC). The client's current vital signs are stable, and the continuous infusion is running on an electronic pump. Which of the following nursing actions must be included in the client's plan of care? Select all that apply.

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Answer: Monitor the client's capillary blood glucose levels at regular intervals of every 4 to 6 hours.; Replace the parenteral nutrition administration tubing and inline filter every 24 hours.; Verify the specific macronutrient and micronutrient ingredients on the dispensed solution label against the provider's prescription.

Answer

The correct actions are to monitor capillary blood glucose every 4 to 6 hours, replace the administration tubing and filter every 24 hours, and verify the specific ingredients on the label against the provider's prescription.
Total Parenteral Nutrition (TPN) is a complex, high-alert therapy requiring meticulous nursing management. Because TPN solutions contain high concentrations of dextrose, clients are at significant risk for therapy-induced blood glucose fluctuations; therefore, routine capillary blood glucose monitoring every 4 to 6 hours is essential. The high glucose and lipid content also creates an ideal medium for bacterial growth, necessitating the strict replacement of the entire administration set and inline filter every 24 hours. Furthermore, due to the highly customized nature of the solution, the nurse must meticulously verify all specific macro- and micronutrients on the bag's label against the original prescription to prevent critical compounding errors.

Step-by-Step Solution

1
Analyze the prescribed therapy and its associated risks.
The client is receiving Total Parenteral Nutrition (TPN) via a central line, which carries significant metabolic, infectious, and compatibility risks.
Recognizing the high-alert nature of TPN guides the prioritization of safety protocols.
2
Evaluate the correct options based on TPN standards of care.
Monitoring blood glucose, verifying exact ingredients, and changing tubing every 24 hours are standard safety protocols.
These specific actions mitigate the inherent risks of hyperglycemia, medication compounding errors, and central line-associated bloodstream infections.
3
Identify and exclude the incorrect nursing actions.
Delegating the site assessment, mixing medications in the line, and increasing the rate to catch up are identified as unsafe.
These actions directly violate delegation guidelines, intravenous compatibility rules, and critical fluid/electrolyte safety limits.

Key Concept

Parenteral Nutrition Administration and Monitoring
Question 12Question →

A registered nurse (RN) on a neurology step-down unit is assigning tasks for the upcoming shift. The nursing team includes the RN, a licensed practical nurse (LPN), and an unlicensed assistive personnel (UAP). Which of the following tasks are appropriate for the RN to delegate? Select all that apply.

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Answer: Assigning the UAP to reposition a bedbound client who is receiving continuous enteral feedings; Assigning the LPN to administer scheduled oral antiepileptic medications to a client who had an ischemic stroke three days ago; Instructing the UAP to empty and document the fluid volume in a closed-wound surgical drainage device

Answer

The RN can safely delegate repositioning a stable client and documenting drainage volume to the UAP, and administering oral medications to a stable client to the LPN.
Delegating routine care such as repositioning a client and documenting drainage volume is appropriate for a UAP because these tasks do not require nursing judgment. Assigning an LPN to administer scheduled oral medications to a client who is clinically stable (three days post-stroke) is also safe and aligns directly with their authorized scope of practice.

Step-by-Step Solution

1
Evaluate each task to determine if it involves initial assessment, clinical judgment, or initial teaching.
Tasks involving swallow screens, developing teaching plans, and formulating care plans require RN judgment and cannot be delegated.
The National Council of State Boards of Nursing (NCSBN) strictly prohibits delegating assessment, teaching, and evaluation to LPNs or UAPs.
2
Determine the appropriate scope of practice for the UAP in the remaining tasks.
Repositioning a client and emptying/documenting drainage are routine tasks safely delegated to a UAP.
UAPs are trained to assist with activities of daily living and basic data collection.
3
Determine the appropriate scope of practice for the LPN in the remaining tasks.
Administering scheduled oral medications to a stable, three-day post-stroke client is an appropriate LPN task.
LPNs are licensed to administer routine oral medications to clients with predictable outcomes.

Key Concept

The RN must retain tasks requiring clinical judgment, comprehensive assessment, and initial teaching, while delegating routine, predictable tasks to LPNs or UAPs based on their established scopes of practice.
Question 13Question →

A registered nurse (RN) enters a preoperative staging area to witness the surgical consent signature for a 65-year-old client scheduled for a pacemaker insertion. The client's spouse and an unlicensed assistive personnel (UAP) are present. The RN notes the client is acutely lethargic and disoriented, which the spouse reports began shortly after the client received a preoperative dose of intravenous midazolam. The surgeon is waiting to proceed and requests the RN to witness the signature immediately so the surgical schedule is not delayed. Which actions by the RN are appropriate in this situation? (Select all that apply.)

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Answer: Intervene to halt the signing process, as the recent administration of a sedative temporarily impairs the client's legal capacity.; Verify the medical record to determine if the spouse is the legally designated healthcare surrogate.; Ensure the surgeon has discussed the procedural risks, benefits, and alternatives with the authorized surrogate.

Answer

The nurse should halt the signing process due to the client's impaired capacity from sedation, verify if the spouse is the designated surrogate, and ensure the surgeon informs the surrogate.
Informed consent requires the client to be competent and acting voluntarily. A client who has received a preoperative sedative like midazolam lacks the legal capacity to sign. The nurse must act as an advocate by halting the process, verifying if the spouse is the legally designated surrogate, and ensuring the surgeon fulfills their duty to explain the risks and benefits to that surrogate.

Step-by-Step Solution

1
Assess the client's capacity to give legal consent.
The client is found to be acutely lethargic and disoriented after receiving intravenous midazolam.
Clients who have received central nervous system depressants or sedating medications are legally considered incompetent to provide valid informed consent.
2
Intervene to prevent the client from signing the document.
The consent process is immediately halted despite the surgeon's request to proceed.
The RN acts as a client advocate to protect the client's legal rights and prevent an invalid consent from being executed.
3
Identify an authorized surrogate decision-maker.
The RN checks the medical record for advance directives or a medical power of attorney.
When a client temporarily lacks capacity, informed consent must be obtained from their legally designated healthcare proxy or surrogate.
4
Verify that the provider has properly informed the surrogate.
The RN ensures the surgeon discusses the procedure with the designated surrogate prior to signature.
The provider is legally responsible for explaining the risks, benefits, and alternatives to the person providing consent.

Key Concept

The registered nurse acts as a client advocate during the informed consent process by assessing cognitive capacity, preventing signatures under the influence of sedatives, and ensuring the provider obtains consent from a legally authorized surrogate.
Question 14Question →

A nurse is caring for a young adult client who was voluntarily admitted to an inpatient psychiatric unit three days ago with severe major depressive disorder. This morning, the client suddenly appears remarkably peaceful, gives their favorite watch to a peer, and states, 'Everything makes sense now. I am leaving this hospital today.' The client demands their personal belongings and attempts to exit the locked unit. Which of the following actions are legally and ethically required by the nurse? Select all that apply.

Select all that apply

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Answer: Contact the healthcare provider immediately to report the client's behavioral changes and demand to leave.; Place the client on continuous one-to-one direct observation immediately.

Answer

The legally and ethically required actions are to contact the healthcare provider immediately and to place the client on continuous one-to-one direct observation.
The correct actions prioritize client safety and appropriate interdisciplinary communication. A client who is voluntarily admitted retains the right to request discharge; however, the facility has a legal duty to protect the client if they pose an imminent threat to themselves. The sudden lifting of depressive symptoms, combined with giving away prized possessions, strongly indicates the client may have formulated a lethal plan. Therefore, the nurse must immediately institute one-to-one observation to ensure safety (the least restrictive effective measure) and notify the healthcare provider so the client can be officially evaluated for an involuntary commitment hold.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client shows a sudden, unexplained lifting of depression and is giving away prized possessions, which are well-documented red flags indicating they have finalized a suicide plan.
Recognizing signs of imminent self-harm is critical before addressing the client's demand to leave the facility.
2
Evaluate the legal status of the client's admission in the context of their current safety risk.
The client is voluntarily admitted, meaning they generally retain the right to request discharge. However, because they pose an immediate, severe danger to themselves, the facility's legal obligation to protect them temporarily supersedes this right.
Understanding the intersection of client rights and the duty to protect dictates how the healthcare team legally responds to an Against Medical Advice (AMA) request.
3
Determine the most appropriate and legally sound nursing interventions.
The nurse must use the least restrictive measure possible (one-to-one observation) to ensure immediate safety and must notify the provider to initiate a formal evaluation for an involuntary psychiatric hold.
Nurses cannot independently revoke a client's voluntary status, but they are legally mandated to implement immediate, non-restrictive safety measures and collaborate with the prescribing provider during a crisis.

Key Concept

While clients with voluntary psychiatric admissions generally retain the right to demand discharge, this right is legally suspended if they present an imminent danger to themselves or others. In such emergencies, nurses have a legal duty to protect the client using the least restrictive means necessary while initiating a formal medical evaluation.
Question 15Question →

A 71-year-old client on a surgical unit is preparing for a bowel resection later today. The client received an intravenous (IV) dose of morphine 45 minutes ago to manage acute abdominal pain. The healthcare provider has asked the registered nurse (RN) to witness the client's signature on the informed consent document. Upon entering the room, the client states, "I am willing to have the surgery, but I honestly do not remember what other options the doctor discussed with me." Which actions should the RN take? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Notify the healthcare provider that the client requires further explanation regarding the alternative treatments.; Inform the healthcare provider that the client is currently unable to legally sign the consent form due to recent opioid administration.; Document the client's statements and the subsequent notification of the healthcare provider in the electronic health record.

Answer

The correct actions include notifying the healthcare provider that the client needs further explanation about alternatives, informing the provider that the client cannot legally sign due to recent opioid administration, and documenting these events in the medical record.
The RN must notify the healthcare provider because explaining surgical alternatives is the provider's responsibility. Furthermore, the client received IV morphine 45 minutes ago, making them chemically impaired and legally unable to sign a consent form. All of these observations and notifications must be thoroughly documented in the electronic health record to maintain a legal account of the client's care.

Step-by-Step Solution

1
Assess the client's competency and understanding of the procedure.
The client lacks understanding of the surgical alternatives and is under the influence of an opioid analgesic.
To validate that the consent is truly informed, voluntary, and given by a legally competent individual.
2
Identify the appropriate nursing interventions based on the assessment.
The RN must halt the consent process, notify the healthcare provider of both the knowledge deficit and the chemically impaired capacity, and document the findings.
The RN acts as a client advocate, ensuring legal and ethical standards are met before an invasive procedure.

Key Concept

Informed Consent
Question 16Question →

A registered nurse is reviewing the transmission-based precaution requirements for clients on a medical-surgical unit. Which of the following clients require the nurse to don a fit-tested N95 respirator and ensure placement in a negative-pressure room? Select all that apply.

Select all that apply

Show answer & explanation

Answer: A client presenting with hemoptysis, night sweats, and suspected pulmonary tuberculosis.; A client with an active, disseminated varicella-zoster virus (chickenpox) infection.; A client diagnosed with rubeola (measles) presenting with Koplik spots and a maculopapular rash.

Answer

The clients who require airborne precautions (N95 respirator and negative-pressure room) are the ones with suspected pulmonary tuberculosis, disseminated varicella-zoster virus, and rubeola (measles).
Airborne precautions are specifically indicated for infectious agents that remain infectious over long distances when suspended in the air. The classic mnemonic 'MTV' (Measles, Tuberculosis, Varicella) helps recall the primary conditions requiring an N95 respirator and an airborne infection isolation room (negative-pressure room).

Step-by-Step Solution

1
Analyze the prompt to determine the required level of precautions.
The requirement for a 'fit-tested N95 respirator' and a 'negative-pressure room' clearly indicates the need for Airborne Precautions.
Identifying the tier of transmission-based precautions specified in the question is necessary to evaluate each client's condition appropriately.
2
Evaluate each client's diagnosis against standard infection control guidelines.
Tuberculosis, varicella (chickenpox), and rubeola (measles) require airborne precautions. Neisseria meningitidis and Bordetella pertussis require droplet precautions. Clostridioides difficile requires contact precautions.
Matching the pathogen to its mode of transmission ensures safe and effective care environment practices.
3
Select all options that match the airborne transmission route.
The clients with tuberculosis, varicella-zoster, and rubeola are selected.
These three conditions generate small infectious particles that remain suspended in the air, necessitating respiratory protection (N95) and specialized ventilation.

Key Concept

Airborne precautions must be implemented for pathogens that are transmitted via small droplet nuclei (less than 5 microns), which include Tuberculosis, Varicella-zoster, and Rubeola (measles).
Estimated Time:1m 0s
Question 17Question →

While conducting an infection control audit across a multispecialty acute care facility, the nursing supervisor observes several staff members interacting with clients on transmission-based precautions. Which of the following observed actions require the nursing supervisor to intervene? (Select all that apply)

Select all that apply

Show answer & explanation

Answer: An unlicensed assistive personnel (UAP) uses an alcohol-based hand rub upon exiting the room of a client with confirmed norovirus gastroenteritis.; A transport technician places an N95 respirator on a client with disseminated herpes zoster before transporting the client to the radiology department.; A unit coordinator cohorts a client with a methicillin-resistant Staphylococcus aureus (MRSA) wound infection in the same room as a client with a vancomycin-resistant Enterococcus (VRE) urinary tract infection.

Answer

The nursing supervisor must intervene when the UAP uses alcohol hand rub for norovirus, when the technician places an N95 respirator on the client during transport, and when the unit coordinator cohorts clients with two different multidrug-resistant organisms.
The actions requiring intervention are those that violate standard infection control protocols. Using an alcohol-based sanitizer is ineffective against norovirus, which requires mechanical friction with soap and water. Placing an N95 respirator on a client during transport is contraindicated; a standard surgical mask should be used to contain exhaled droplets without unnecessarily increasing the client's work of breathing. Finally, cohorting clients with different multidrug-resistant organisms (MRSA and VRE) creates a severe risk for cross-contamination and is strictly prohibited.

Step-by-Step Solution

1
Analyze the question stem to identify the nurse's objective.
The stem asks which actions 'require the nursing supervisor to intervene,' meaning the correct answers are the unsafe, incorrect, or contraindicated actions.
Correctly identifying a negatively phrased question is critical to selecting the right options on the NCLEX.
2
Evaluate the hand hygiene method for norovirus.
Norovirus is an enteric pathogen that requires strict handwashing with soap and water; alcohol-based sanitizers are insufficient. This action is unsafe and requires intervention.
Non-enveloped viruses resist alcohol-based sanitizers.
3
Evaluate the PPE donning and doffing techniques.
Removing an N95 outside a negative-pressure room is correct. Donning PPE in the order of gown, mask, shield, and gloves is also correct. These actions are safe and do not require intervention.
Following strict CDC sequencing prevents self-contamination and inhalation of airborne pathogens.
4
Evaluate the transport protocol for Airborne precautions.
Placing an N95 respirator on a client is incorrect; clients should wear standard surgical masks to contain source secretions. This action is unsafe and requires intervention.
An N95 protects the wearer from inhalation, whereas a surgical mask contains the wearer's exhalation. N95s on clients can compromise their respiratory effort.
5
Evaluate the cohorting and room assignment rules.
Cohorting MRSA and VRE together is dangerous and incorrect. Leaving the door open for Droplet precautions (Neisseria meningitidis) is safe and acceptable.
Clients must have the exact same organism to be cohorted. Droplet precautions do not require negative pressure or a closed door.

Key Concept

Transmission-Based Precautions (Airborne, Droplet, Contact, and Enteric) require specific interventions regarding hand hygiene, personal protective equipment (PPE) sequencing, client transport, and room assignments.
Estimated Time:2m 0s
Question 18Question →

During morning rounds, the healthcare team is reviewing isolation protocols for an adult client with a sacral pressure injury that is actively draining and cultured positive for Methicillin-resistant Staphylococcus aureus (MRSA). Which of the following interventions must be included in the client's plan of care? (Select all that apply)

Select all that apply

Show answer & explanation

Answer: Dedicate noncritical patient-care equipment, such as a blood pressure cuff and stethoscope, exclusively to this client.; Don a clean gown and gloves prior to entering the client's room.; Assign the client to a private, single-patient room.

Answer

The correct interventions are dedicating noncritical equipment to the client, donning a gown and gloves before entry, and assigning the client to a private room.
Methicillin-resistant Staphylococcus aureus (MRSA) is primarily spread through direct physical contact with the client or indirect contact with contaminated surfaces. Therefore, contact precautions must be implemented. These precautions mandate placing the client in a private room to limit exposure to others. Healthcare workers must wear a gown and gloves upon entering the room to prevent contamination of their hands and uniforms. Furthermore, dedicating reusable equipment (such as stethoscopes and blood pressure cuffs) solely to the infected client is critical to prevent the mechanical transfer of the bacteria to other vulnerable clients.

Step-by-Step Solution

1
Identify the transmission route for the pathogen mentioned in the scenario.
Methicillin-resistant Staphylococcus aureus (MRSA) is transmitted through direct and indirect physical contact.
Determining the mode of transmission dictates which tier of transmission-based precautions is required.
2
Select the appropriate isolation interventions for contact transmission.
Contact precautions require a private room, the use of gowns and gloves upon entry, and dedicated patient-care equipment.
These physical barriers prevent the transfer of the pathogen from the client or their environment to healthcare workers and other clients.
3
Evaluate the remaining options for clinical appropriateness and scope of practice.
Negative-pressure rooms and surgical masks are eliminated because they are for airborne and droplet transmission, respectively. Delegating wound assessment is eliminated because it violates scope of practice rules.
MRSA does not typically spread through respiratory droplets or airborne routes, and patient assessment is strictly the responsibility of the registered nurse.

Key Concept

Contact Precautions and Appropriate Delegation
Question 19Question →

During a midday interdisciplinary huddle on a neurology acute care unit, the nursing staff reviews sudden changes in the conditions of several assigned clients. Which of the following client situations require immediate nursing intervention? Select all that apply.

Select all that apply

Show answer & explanation

Answer: A client with Guillain-Barré syndrome whose forced vital capacity has decreased from 25 mL/kg to 12 mL/kg over the past four hours.; A client with a T6 spinal cord injury who suddenly reports a severe, pounding headache and exhibits profuse diaphoresis.; A client recovering from a traumatic brain injury who develops new-onset restlessness and a widened pulse pressure.

Answer

The situations requiring immediate intervention are the client with Guillain-Barré syndrome experiencing a decrease in forced vital capacity, the client with a T6 spinal cord injury developing a severe headache and diaphoresis, and the client with a traumatic brain injury showing new-onset restlessness and a widened pulse pressure.
The correct choices all describe acute, life-threatening neurological emergencies. A decreasing forced vital capacity in Guillain-Barré syndrome indicates the paralysis has reached the respiratory muscles, which will cause respiratory failure (Airway/Breathing). A sudden severe headache and diaphoresis in a client with an injury at or above T6 are hallmark signs of autonomic dysreflexia, leading to a severe hypertensive crisis (Circulation). New-onset restlessness and a widened pulse pressure in a traumatic brain injury client are components of Cushing's triad, indicating rapidly increasing intracranial pressure (Disability). All three require immediate nursing intervention and provider notification.

Step-by-Step Solution

1
Evaluate each client's presentation against the Airway-Breathing-Circulation (ABC) framework.
The Guillain-Barré client has a breathing/airway threat, the spinal cord injury client has a circulatory threat (hypertensive crisis), and the brain injury client has a severe neurological/disability threat.
Prioritization requires the nurse to address immediate threats to life or profound physiological instability first.
2
Analyze the remaining neurological symptoms to distinguish between expected chronic findings and acute deterioration.
The symptoms presented by the clients with myasthenia gravis and Parkinson's disease are expected chronic manifestations of their respective illnesses.
Clients with expected, stable manifestations of chronic diseases do not require immediate life-saving interventions compared to those with newly developing acute complications.

Key Concept

Prioritizing Acute Neurological Emergencies Over Expected Chronic Findings
Question 20Question →

An alert and oriented 78-year-old client with end-stage heart failure is admitted to the progressive care unit. The client explicitly requests a "Do Not Resuscitate" (DNR) status and refuses any future mechanical ventilation. The client's adult child, who is the legally designated healthcare proxy, arrives and demands that the healthcare team "do everything possible," including intubation if necessary. Which of the following ethical nursing actions should the nurse take? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Communicate the client's explicit end-of-life wishes to the primary healthcare provider.; Explain to the adult child that the healthcare proxy designation is only active if the client loses decision-making capacity.; Reassure the client that their right to refuse medical treatment will be respected by the healthcare team.

Answer

The correct actions are to communicate the client's wishes to the provider, explain the limitations of the healthcare proxy to the adult child, and reassure the client that their autonomous decisions will be respected.
The core ethical principle of autonomy guarantees a competent client the right to make their own healthcare decisions, including the refusal of life-sustaining treatment. A healthcare proxy (durable power of attorney for healthcare) only holds decision-making authority when the client is deemed legally or clinically incompetent. Therefore, the nurse must advocate for the client by ensuring their wishes are immediately communicated to the provider for formal orders, educating the family on these legal boundaries, and validating the client's autonomous choices.

Step-by-Step Solution

1
Assess the client's current competency and decision-making capacity.
The client is alert, oriented, and competent to make healthcare decisions.
Competency determines who holds the legal right to dictate the plan of care.
2
Identify the ethical conflict between the client's autonomy and the family member's demands.
The client's right to refuse treatment supersedes the adult child's wishes, as a healthcare proxy is only enacted when the client is incapacitated.
Ethical practice requires prioritizing the competent client's autonomy over surrogate demands.
3
Select interventions that advocate for the client's rights.
The nurse must notify the provider to obtain the DNR order, educate the family on legal boundaries, and support the client emotionally.
These actions directly uphold the principles of autonomy, veracity, and advocacy without causing harm or unnecessary delay.

Key Concept

Client Autonomy and Healthcare Proxy Activation
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